SUMMARY
The child Z.A, 11 years old was referred to the trainee clinical psychologist with the complain of
speech and learning problems. The client was assessed with both informal and formal level. In
informal assessment history, behavioral observation and rating on the problematic areas were taken
from the client’s mother. Where as in formal assessment with colored progressive matrices and
portage guide for early education were administered. After the thorough assessment client was
diagnosed as the patient of Intellectual Developmental Disorder and comprehensive
developmental plan was made according to presenting complaints and symptoms of patient. The
management plane was based on supportive therapy, Applied behavior analysis (ABA), Art
therapy, Behavior therapy and supportive therapy. Techniques like positive reinforcement,
modeling, matching and sorting, social skill training sensory room activities proves very effective
and bought 30% improvement in the symptoms of the patient. The informant reported 20%
improvement in his behavioral problems, 15% improvement in his academic problems and other
related problems. As long-term goals continuation of short term goals. The patient are benefited
from the follow up therapies and techniques.
BIO DATA
Name: Z.A
Gender: Male
Age: 11
Date of birth: 04-10-2011
Siblings: 1 sister
Birth order: Elder
Father occupation: Army officer
Father status: Died
Mother status: alive
Socio economic status: middle
Family status: Nuclear
Religion: Islam
Informant: Mother and Teacher
REASON AND SOURCE OF REFERRAL
The client was admitted in Army Public School. He was referred to the trainee clinical
psychologist for assessment and management with impression of intellectual disability.
PRESENTING COMPLAINTS
The client was referred with the following complaints reported by the informant
• Inattention
• Difficulty in speech
• Difficulty in learning
• Difficulty in initiating new tasks
• Deficits in problem solving
• Difficulty in reading and writing
• Difficulty initiating conversation
• Difficulty ignoring distracting stimuli
• Difficulty to follow instructions
• Difficulty in maintain eye contact
• Restless
• Hyperactive (Mild)
• Visual impairment
HISTORY OF PRESENT ILLNESS
According to client's mother, The client had a high fever after her birth. He was admittted
in hospital for 14 days. the client have history of delayed developmental milestones but significant
in speech and visual area. Client mother reported that client started speaking single word at the age
of 1 year. He started head control at the age of 6-8 months and he started walking at the age of 1
year and 8 months delayed from his expected age. He start sitting at the age of 9 months. His
speech was also delayed. He also did not have bowl and bladder control before the age of 6 and
could not dressed by him self till now. The only problem for the client family was the client’s
speech and leaning difficulties. He could not talk because he has speech problem. He show
restlessness during class.
BACKGROUND INFORMATION
Family History:
The client live in nuclear family and belong to nuclear family. he was 6 years old when
his father was died. He was educated and serving as armed force as a soldier. The client mother
was 31 years old and educated up to matric and was a house wife. She cares about his children,
about his health and about his education. Both the client and his mother has fair relationship. They
have good understanding. They want the progress of their child.The client had only one sister. Her
behavior with the client is good and on every point she support him. She have good relation with
the client. the client was attached with mother and father. overall, the client' family was very
loveable.
Family Genogram:
Parenting Style:
The authoritarian style was practicing in the family.
Developmental history:
The client mother had faced many complication during pregency. During pregnancy his
mother faced high blood pressure. Mother's reported child achieved his developmental milstones
inadequate age. developmenal milstones was delayed. The developmental history of client was as
follows.
Table No 1
This table show client developmental milestones.
________________________________________________________________________
Developmental Milestones Participants Age of Achievement
Head Control 6-8 months
Walking 1 year and 8 months
Speech 1 year
Sitting 9 months
________________________________________________________________________
Educational History:
The client started going to school in Special Education Academy at the age of 6 years. He
has poor eye contact. As reported by his teacher that he was slow in studies. He also don’t give
attention to studies and easily forget the pervious lesson.
Social History:
The client is socially active. He has interest in social activties. she play with her sister and
friends.
Sexual History:
Client's mother reported thathe has not significant sexual history.
History of psychiatrist/physical illness in family:
There was no history of psychiatric and physical illness in the family.
PSYCHOLOGICAL ASSESSMENT
Psychological assessment was comprised of informal and formal assessment
INFORMAL ASSESSMENT
CLINICAL INTERVIEW
A semi structured interview was conducted in order to gather complete history and
information about the client’s problem. In interview foucs all the factors that influence child life.
BEHAVIORAL OBSERVATION
The client is a fair child of average height. He wears neat and clean dresses. He had difficulty in
speech. He cannot adequately maintain his eye contact. He showed much interest towBASE Based
Line
Base line is the period during which the target behavior is recorded before treatment is
implemented. Base line was taken for the client’s learning problemsard playground. He shows
mild restlessness and easily distracted. Rating scale to obtain to obtain information on the target
behavior from the individual exhibiting the behavior.
Table No 2
Table shows pre and post assessment of client
_______________________________________________________________________
BEHAVIOR PRE-ASSESSMENT POST-ASSESSSMENT
Problem in memorizing lesson 10 07
Difficulty in remembering things 10 07
Deficit in problem solving skills 10 08
Difficulty in reading and writing 10 06
Difficulty following instructions 09 05
Spelling mistakes 10 06
poor memory 10 08
Hyperactivity 04 02
Aggressive 08 06
Restless 06 04
________________________________________________________________________
GRAPHICAL PRESENTATION:
MINI MENTAL STAUTS EXAMINATION
MMSE were administer to assess client cognition impairment.
Table No 4
This table shows client scoring on MMSE.
________________________________________________________________________
AREAS ASSESS IST TRIAL 2ND TRIAL 3RD TRIAL
SCORES SCORES SCORES
__________________________________ _____________ _________ __________
ORIENTATION TO TIME 0/5 0/5 0/5
ORIENTATION TO PLACA` 0/5 0/5 0/5
REGISTRATION 1/3 1/3 1/3
ATTENTION AND CALCULATION 0/5 0/5 1/5
RECALL 1/3 1/3 2/3
LANGUAGE 0.5/2 1/2 1/2
REPITITION 0/1 0/1 0/1
COMPLEX COMMANDS 1/3 1/3 2/3
1/1 1/1 1/1
0/1 0/1 0/1
COPYING 0/1 0/1 0/1
__________________________________ _____________ __________ ____________
TOTAL 4/30 5/30 8/30
__________________________________ _____________ __________ _____________
QUALITATIVE ANALYSIS
In MMSE client 1st trial total score was 4, 2nd trial score was 5 and 3rd trial score was 8 out
of 30 so it interpreted that client have severe cognitive impairment
FORMAL ASSESSMENT
INTELLECTUAL ABILITY ASSAMENT
COLOURED PROGRESSIVE MATRICES (CPM)
CPM was administered to have an idea of IQ level of client.
Table No 5
This table show client scores and IQ level.
________________________________________________________________________
SCORE A SCORE B SCORE C TOTAL INTERPRETATION
4 1 1 6 IQ below average
QUALITATIVE ANALYSIS
The client total score is 6 which indicates that his IQ level is below average.
ADAPTIVE BEHAVIOR
PORTAGE GUIDE TO EARLY EDUCATION (PGEE)
portage guide for early education (PGEE) were administered to assess about client
developmental abilities.
Table No 6
The table showing the PGEE areas and the client’s developmental functioning level
accordingly
_______________________________________________________________________
AREAS first item
missed cooresponding age last item missed corresponding age
________________________________________________________________________
Self help 35 2-3 years 42 2-3
Language 17 1-2 years 31 2-3
Socialization 38 2-3 years 49 2-3
Cognitive 68 2-3 78 3-4
Motor 84 3-4 years 93 4-5
_______________________________________________________________________
Missed items on the PGEE
QUALITATIVE ANALYSIS
Analysis of PGEE revealed that the client is three years below than his chronlogical age in
the areas of self help whereas he is two years below then his chronological age in motor area. and
four year below his chronoogical age in language. in cognitive area the client area is 2 years blow
then his chronologiacl age. In socialization the client is four year old then his chronlogical age.
NEUROLOGICAL TEST
BENDER GUESTALT TEST (BGT)
To assess client visual and brain impairment.
Table No 7
This table shows client scores on BGT.
________________________________________________________________________
Card Design No Time of showing Time to reproduce Errors
each card In copy
________________________________________________________________________
A 30 sec 12 sec 1
1 30 sec 25 sec 1
2 30 sec 40 sec 1
3 30 sec 35 sec 1
4 30 sec 40 sec 1
5 30 sec 43 sec 1
6 30 sec 37 sec 1
7 30 sec 25 sec 1
8 30 sec 33 sec 1
9 30 sec 42 sec 1
QUALITATIVE ANALYSIS
As shown in the table that client have error on every design which interpret that client have
severe visual and brain impairment.
CASE FORMULATION
The child Z.A, 11 years, was referred to the trainee clinical psychologist with the impression of
intellectual disability.
Brooks and Mc Caulcy (1984) have postulated that many of the learning problems with relation to
attention problems, as cited in Hallaham (1997). As in the present case, the teacher complained of
inattention.
Agran et al, in 1987 have suggested that deficit in memory are associated with an inability to focus
on relevant stimuli in learning situation and may be deficit in the development of learning sets, as
cited in Hallaham (1997). In the present case, the client also did not focus on the relevant stimuli
in learning situation.
DIAGNOSIS
318.1 (F72) Severe Intellectual Developmental Disorder
MANAGEMENT PLAN
• Psychoeducation
• Applied Behavioral Analysis (ABA)
• Sensory Room Activities
• Art Therapy
• Speech therapy
SHORT-TERM GOALS
• to develop the rapport with the clientwith the help of supportive work.
• Psycho education of the client mother will be carried out regarding the nature of the client
illness and related issues.
• Individualized educational plan to meet the client’s needs and improve learning.
• Role play is used to engage the child i social activties.
• Art activities will be used to help client to building positive experience and self-confidence.
• Social skills training will be used like modeling to Improve interactional skills in different
situations.
• Positive reinforcement will be used to help him to comment and notice
• Sensory room activities is used to improve client attention.
• Speech therapy will be used to improve his speech
• ABA is used to improve the client behavior.
LONG-TERM GOALS
• Continuation of short-term goals.
• continuation of follow up session
• continution of therapeutic session to maintain leaened work.
Summary of Therapeutics Intervention:
Rapport building;
initially the rapport was buld with the help of supportive work, active listening, and empthy
was included. with the help of good repport the therapy progressed well.
Psychoeducation
Psychoeducation for parent is ment to inform them about their children's problems. parents
can understand the homework related to child problems.
Role play:
Role play is very helpful technique to engage the child with activites. with the help of
technique the client suggest how to pllay with the other child.
Token Economy:
token economy is an extermely effective contingency system. this technique help to change
undesireable behavior to desireablr behavior. for example, in this case client not learn lesson.
psychologist says if you write this work i give one star.
Applied Behavior Analysis
ABA techniques replace the child behaviors. Teacher give commands . for example we instead
instruct them to tap on the arm and say excuse me. the client help to reduce inapporpiate
behavior. In sensory room his play with ball and put same color box that activty help to
recognized the colors.
Reinforcement
Positive reinforcement can be more effective. this is a fundamental aspect of ABA therapy.
with the help of techniques to improve his intention span.
THERAPUTIC OUTCOMES
The client took 16 sessions. Rapport was build with the client in initial session. Due to good rapport
the client attended every session and he had been following the homework and assignment
regularly. Different techniques were used to improve client’s behavior, learning and behavior
problems. The informant reported 40% improvement in his behavioral problems, 20%
improvement in his academic problems and other related problems. Client become confident due
to his improved study habits. Due to client cooperative behavior the therapy progressed well.
